Update from the AHA 2010
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Update from the AHA 2010
Jonathan SilberbergFebruary 2011
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Part 1. Trials• Rocket-AF• Closure I• Emphasis-HF• SMART• Fish oil and AF• Symplicity-HTN 2
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Rocket-AF
• Trial of rivaroxiban in AF• oral Factor Xa inhibitor• Half life 5-12 hours, given once
daily• Dose reduction in renal failure
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Rocket-AF
• High CHAD-2 score ~3.5 ave• 90% >3, cf. previous trials ~2.0• 55% prior stroke• 63% heart failure, 40% diabetes• N=14,171
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Rocket-AF
• warfarin-treated target INR 2-3• Median time in range 58%• Over range12%• Under range 20%• Up to 40 months followup
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Rocket-AFRivaroxaban Warfarin
N 7081 7090
Intracranial/cerebral bleed 84 55
Stroke or embolism 269 306
‘Primary endpoint’ 2.12% 2.42%
‘noninferiority’ 1.71% 2.16%
Patients were already stable on warfarin before randomisation
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conclusions• Warfarin monitoring is suboptimal even
in well-funded trials• Under-anticoagulation protects against
bleeding; more consistent treatment brings higher bleeding rates
• Absolute stroke rates may be overestimated
• Benefits of treatment are small
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StarFlex Closure I
• N=909• Age 18 to 60• Cryptogenic stroke and PFO• Open label • ASA or WarfarinvsStarFlex with
ASA/clopidogrel
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StarFlex Closure IDevice Medical
stroke/TIA/ neuro deathWithin 2 years
5.5% 7.7%
Stroke in 2 years 3.1% 3.4%
Recurrent stroke 23 29
Alternative cause 20 22
PFO is usually incidental to stroke
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Emphasis-1
• Eplerenone in mild heart failure• N=2737, average 5 years CHF• EF <35%; NYHA class II• 65% coronary disease• median 21 mo followup
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Emphasis-1eplerenone placebo
CV death 10.8% 13.5%
hospitalisation 12.0% 18.4%
Death or hospital 18.3% 25.9%
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Absolute 15.5% vs 12.5%NNT 33 for 3 years
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EMPHASIS-1
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SMART
• A-V delay in CRT (biventricular pacing)
• N=980, CHF with mean EF 24%• Empirical 120 msecvs• H’dynamic max dP/dtvs• Supine echo algorithm
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Fish oil and AF
• N=542 paroxysmal AF• N=121 persistent AF• 4g omega-3 vs placebo• 24 weeks
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Fish oil and AF
Participants were at least 18 years old and had a confirmed diagnosis of either symptomatic paroxysmal AF that had never been treated by long-term pharmacological or electrical therapy to terminate an AF episode
or had a diagnosis of symptomatic persistent AF, defined as AF that had been previously successfully treated with pharmacological or electrical cardioversion at least 1 time and were currently in normal sinus rhythm.
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Fish oil and AF
Inclusion required at least 1 suspected ordocumented episode of symptomaticAF within 3 months of screening andat least 1 electrocardiographicallydocumented episode of symptomaticAF within 12 months of screening.
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Symplicity-HTN 2
• Ardian device renal denervation• SBP >160 despite 3 drugs• Omron automatic oscillometry• home and office BP• 84/190 fell <160 during run-in
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Next week...part 2
• Cardiac hypertrophy• Decompensated heart failure• Brown & Goldstein• PHT in heart failure• LDL cholesterol• Thoracic aorta